Humana
Base Pay Range
$71,100.00/yr - $97,800.00/yr Become a part of our caring community and help us put health first. Overview
The Pre‑Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre‑Authorization Nurse 2’s work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Responsibilities
Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines to include timely data entry in MSR. Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases appropriately to second level review and follow up with any denial activities as indicated. Complete and document in MSR accurate and timely determinations of appropriateness of level of care; take appropriate actions to facilitate direction of patients to correct level of care as indicated by criteria. Direct discharge planning appropriately; maximize steerage of patients to the MTFs and preferred providers; facilitate move to alternative levels of care in a timely manner. Identify and follow patients requiring Tier II Care Management. Coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate. Required Qualifications
Our Department of Defense Contract requires U.S. citizenship for this position. Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service). HGB is not authorized to do work in Puerto Rico per our government contract (candidates living in Puerto Rico cannot be hired). Registered Nurse with current in‑state RN license. At least 3 years of varied clinical RN nursing experience. Current TRICARE experience. Current knowledge of MCG evidence‑based criteria or comparable (e.g., InterQual). Preferred Qualifications
Utilization Review/Quality Management experience. BA/BSN degree. Work‑At‑Home Requirements
Must have the ability to provide a high‑speed DSL or cable modem for a home office. For California residents, a stipend is provided for internet expense. Minimum standard speed for optimal performance of 25x10 (25 Mbps download × 10 Mbps upload) is required. Satellite and wireless internet service is NOT allowed for this role. Dedicated, interruption‑free space required to protect member PHI/HIPAA information. Travel
– While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required. Scheduled Weekly Hours
40 Pay Range
$71,100 - $97,800 per year. The compensation range reflects a good‑faith estimate of starting base pay for full‑time (40 hours per week) employment at the time of posting; it may vary based on geographic location and individual qualifications. Bonus Incentive Plan
– This job is eligible for a bonus incentive plan based on company and/or individual performance. Description of Benefits
Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole‑person well‑being. Benefits include medical, dental and vision coverage; 401(k) retirement savings plan; paid time off (including company and personal holidays, volunteer time off, paid parental and caregiver leave); short‑term and long‑term disability; life insurance; and other opportunities. About Us
Humana Inc. (NYSE: HUM) is committed to putting health first – for teammates, customers and the company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for millions of people we serve to achieve their best health. Equal Opportunity Employer
Humana does not discriminate against any employee or applicant for employment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana is committed to affirmative action and hiring individuals with disability or protected veteran status, and it bases all employment decisions only on valid job requirements. Seniority Level
Mid‑Senior level Employment Type
Full‑time Job Function
Health Care Provider Industries
Insurance
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$71,100.00/yr - $97,800.00/yr Become a part of our caring community and help us put health first. Overview
The Pre‑Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forwards requests to the appropriate stakeholder. The Pre‑Authorization Nurse 2’s work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Responsibilities
Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines to include timely data entry in MSR. Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases appropriately to second level review and follow up with any denial activities as indicated. Complete and document in MSR accurate and timely determinations of appropriateness of level of care; take appropriate actions to facilitate direction of patients to correct level of care as indicated by criteria. Direct discharge planning appropriately; maximize steerage of patients to the MTFs and preferred providers; facilitate move to alternative levels of care in a timely manner. Identify and follow patients requiring Tier II Care Management. Coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate. Required Qualifications
Our Department of Defense Contract requires U.S. citizenship for this position. Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service). HGB is not authorized to do work in Puerto Rico per our government contract (candidates living in Puerto Rico cannot be hired). Registered Nurse with current in‑state RN license. At least 3 years of varied clinical RN nursing experience. Current TRICARE experience. Current knowledge of MCG evidence‑based criteria or comparable (e.g., InterQual). Preferred Qualifications
Utilization Review/Quality Management experience. BA/BSN degree. Work‑At‑Home Requirements
Must have the ability to provide a high‑speed DSL or cable modem for a home office. For California residents, a stipend is provided for internet expense. Minimum standard speed for optimal performance of 25x10 (25 Mbps download × 10 Mbps upload) is required. Satellite and wireless internet service is NOT allowed for this role. Dedicated, interruption‑free space required to protect member PHI/HIPAA information. Travel
– While this is a remote position, occasional travel to Humana’s offices for training or meetings may be required. Scheduled Weekly Hours
40 Pay Range
$71,100 - $97,800 per year. The compensation range reflects a good‑faith estimate of starting base pay for full‑time (40 hours per week) employment at the time of posting; it may vary based on geographic location and individual qualifications. Bonus Incentive Plan
– This job is eligible for a bonus incentive plan based on company and/or individual performance. Description of Benefits
Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole‑person well‑being. Benefits include medical, dental and vision coverage; 401(k) retirement savings plan; paid time off (including company and personal holidays, volunteer time off, paid parental and caregiver leave); short‑term and long‑term disability; life insurance; and other opportunities. About Us
Humana Inc. (NYSE: HUM) is committed to putting health first – for teammates, customers and the company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for millions of people we serve to achieve their best health. Equal Opportunity Employer
Humana does not discriminate against any employee or applicant for employment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana is committed to affirmative action and hiring individuals with disability or protected veteran status, and it bases all employment decisions only on valid job requirements. Seniority Level
Mid‑Senior level Employment Type
Full‑time Job Function
Health Care Provider Industries
Insurance
#J-18808-Ljbffr